<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Name')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-name" data-rule="required" class="form-control" name="row[name]" type="text" value="{$row.name|htmlentities}">
        </div>
    </div>
    <!-- <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Admin_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-admin_id" data-rule="required" data-source="auth/admin/selectpage" data-field="nickname" class="form-control selectpage" name="row[admin_id]" type="text" value="{$row.admin_id|htmlentities}">
        </div>
    </div> -->
    <div class="form-group ">
        <label class="control-label col-xs-12 col-sm-1"></label>
        <div class="col-xs-12 col-sm-10">
            <div class="well">
                <div style="display: flex;"><h5 style="text-align: center;font-weight: 600;">公车加油</h5></div>
                <div style="display: flex;">
                    <div class="form-group" style="width: 50%;">
                        <label class="control-label label-margin">{:__('Examine_id')}:</label>
                        <div class="col-xs-12">
                            <input id="c-examine_id" data-rule="required" data-source="auth/admin/selectpage" data-field="nickname" class="form-control selectpage" name="row[examine_id]" type="text" value="{$row.examine_id|htmlentities}">
                        </div>
                    </div>
                </div>
            </div>
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-primary btn-embossed disabled">{:__('OK')}</button>
        </div>
    </div>
</form>

<style>
    .label-margin {
        margin-left: 18px;
    }
</style>
